Surgical Case 01 Marilyn Hughes DA PDF

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VSIM. Surgical Case #1. Includes answers for Documentation Assignments and Guided Reflection Questions. ...

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Surgical Case 1: Marilyn Hughes Documentation Assignments 1. Document a comprehensive pain assessment for Marilyn Hughes. a. During the first assessment Marilyn graded her pain at an 8/10 saying the pain was in her left leg and that it was numb, and the dressing was too tight. After completing the interventions, she graded her pain a 6/10, still in her left leg, but saying the dressing felt better 2. Document Marilyn Hughes’ neurovascular assessment. a. She said her whole left leg felt numb and was not able to move or feel her toes on her left side. There was no pulse present on the left foot. 3. Document the changes in Marilyn Hughes vital signs. a. During my initial assessment, Marilyn’s vital signs included a heart rate of 99, blood pressure of 155/92, respirations of 21, SpO2 of 97% and temperature of 99F. After doing my interventions her vital signs were; heart rate 98, blood pressure 153/92, Respirations 21, SpO2 98%, and temperature 99F 4. Identify and document key nursing diagnoses for Marilyn Hughes. a. 5. Referring to your feedback log, document the nursing care you provided and Marilyn Hughes’ response to this care. a. After getting vitals, I performed a neurovascular assessment and found that her left leg was not getting adequate circulation based on the fact that I could not feel a pulse, and the patient couldn’t feel or move her toes. I then loosen her dressing and placed her leg at heart level position instead of above the heart. After doing this, the patient reported less pain.

Guided Reflection Questions 1. How did the scenario make you feel? a. I felt frustrated during this scenario because after doing all the interventions that I could, the patient reported a pain score of 6/10 which I thought was still too high. I knew she had compartment syndrome and every time I called the physician; he didn’t give me any new orders. I thought there would be more interventions for me to do for compartment syndrome but there was not. 2. How would you recognize that Marilyn Hughes’ condition was deteriorating? a. An increase in pain without any relief, a decrease in circulation to the leg, decrease in neurosensory in the leg. 3. What interventions exist to alleviate compartment syndrome, and what assessments indicate improved perfusion to the extremity? a. Loosening the dressing and placing the affected limb at heart level.

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b. Capillary refill less than 3 seconds, finding a pulse, skin color pink and healthy, affected limb warm to touch and not cold or diaphoretic, patient is able to move extremities that are distal to the sight of injury. Why is it important to maintain the limb at heart level versus elevating it above heart level? a. Heart level is preferred because if the limb is elevated it decreases arterial flow and narrows the arterial venous pressure gradient What could have happened in this scenario if Marilyn Hughes’ condition was not treated expediently? a. If not treated soon, Marilyn could have been a great candidate for a fasciotomy. What key elements would you include in the handoff report for this patient? Consider the SBAR (situation, background, assessment, recommendation) format. a. S: Patient is experiencing intense pain in her left leg. she is unable to move or feel her toes and there was no pulse detectable in her left foot b. B: Patient fell on ice and had an ORIF on her left tibia and fibula c. A: She is unable to move or feel her toes and there was no pulse detectable in her left foot d. R: I believe Marilyn is experiencing acute compartment syndrome and her left leg should be placed at heart level and her dressing should be redone so that it is not so tight around her leg. What would you do differently if you were to repeat this scenario? How would your patient care change? a. I would have lowered the patient’s leg to the level of her heart as one of my first interventions after I recognized it was compartment syndrome because if I completed this intervention earlier, my patient’s pain score might have been lower by the end of the scenario.

© Wolters Kluwer Health | Lippincott Williams & Wilkins

© Wolters Kluwer Health | Lippincott Williams & Wilkins...